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Neonatal paratesticular abscess mimickingperinatal torsion

Chris Briggsa, Prasad Godbolea,*, A. Ewen MacKinnona, Karl Vermeulenb

aDepartment of Paediatric Urology, Sheffield Children’s Hospital, S10 2TH Sheffield, UKbDepartment of Histopathology, Sheffield Children’s Hospital, S10 2TH Sheffield, UK

0022-3468/$ – see front matter D 2005

doi:10.1016/j.jpedsurg.2005.03.066

T Corresponding author. Departmen

Children’s Hospital, Sheffield S10 2TH

fax: +44 114 276 8419.

E-mail address: prasadgodbole@btin

Index words:Perinatal torsion;

Testicular abscess

Abstract Management of perinatal torsion varies between centers from urgent surgical exploration and

contralateral fixation to conservative nonoperative management. We present a case of paratesticular

abscess in a neonate mimicking a perinatal torsion which may influence management of this condition

in some cases.

D 2005 Elsevier Inc. All rights reserved.

There is controversy regarding treatment of perinatal

torsions [1]. Conservative or delayed surgical intervention is

based on reports that the testis is never salvageable [2]. Our

case of a neonate presenting with a paratesticular abscess

mimicking a perinatal torsion supports the practice of urgent

surgical exploration at least in some cases and consideration

given to the possibility of preservation of the testis.

1. Case report

An 11-day-old boy was referred as an emergency with a

right testicular swelling of less than 24 hours’ duration. The

clinical diagnosis was of a perinatal torsion. An ultrasound

revealed a normal left testis and appearances consistent with

a perinatal torsion on the right, namely, absence of any

evident blood flow. Renal tract ultrasound was normal.

While on the ward, he was coincidentally noted to have a

paronychia of his left thumb. At surgery, the right testis

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t of Paediatric Surgery, Sheffield

, UK. Tel.: +44 114 271 7000;

ternet.com (P. Godbole).

appeared to be necrotic with frank pus in the scrotum. The

testis was resected, and the contralateral side was fixed.

Histology of the resected specimen showed evidence of

focal suppuration and repair within the layers of the tunica

vaginalis consistent with a paratesticular abscess (Fig. 1).

Journal of Pediatric Surgery (2005) 40, 1195–1196

Fig. 1 High-power view of the testis in Fig. 1 showing tissue

necrosis and an inflammatory cell infiltrate (N), with adjacent

granulation tissue (G). The inset shows normal seminiferous tubules.

C. Briggs et al.1196

Surprisingly, the testicular parenchyma itself appeared

normal (Fig. 2). Culture of the pus grew a coliform

organism, and findings in the urinalysis were normal. After

orchidectomy, he made an uneventful recovery.

ig. 3 Testicular torsion. The testicular parenchyma (T) is

ongested and hemorrhagic, and the seminiferous tubules are

artially necrotic. The inset shows a high-power view of the

eminiferous tubules (compare this to the inset in Fig. 2, which was

ken at the same magnification). T indicates testis; E, epididymis.

2. Discussion

A single reported case of a neonatal testicular abscess

secondary to aerobic and anaerobic organisms, the focus of

which could not be found, has been described before [3].

The etiology of such an abscess is obscure. In our case,

isolation of a coliform organism from the abscess goes

against hematogenous spread from the paronychia in our

case. Clinical features and ultrasound findings were

indistinguishable from the typical appearances in perinatal

torsion [4]. Most cases of neonatal torsion are believed to

be secondary to vascular insult and infarction followed by

testicular necrosis [5]. The typical features of perinatal

torsion are shown in Fig. 3, which do not correspond with

Fig. 2 Case specimen showing a paratesticular abscess. The arrow

points to an area of tissue necrosis with an associated inflammatory

infiltrate. T indicates testis; E, epididymis; TV, tunica vaginalis.

Fc

p

s

ta

our case. Current practice in some centers is not to explore

the scrotum or to explore the scrotum electively in unilateral

perinatal torsion on the basis that the testis can never be

saved. Our case provides a caution to this approach as it

is possible that the testis would have survived with drainage

of the abscess and postoperative antibiotics.

References

[1] Schimmel MS, Prat O. Perinatal acute scrotum: controversies in

the management of torsion of the testis. Am J Dis Child 1993;147(9):

933 -4.

[2] Brandt MT, Sheldon CA, Wacksman J, et al. Prenatal testicular torsion:

principles of management. J Urol 1992;147(3):670 -2.

[3] Singh D, Dutta S, Kumar P, et al. Mixed anaerobic and aerobic

testicular abscess in a neonate. Indian J Pediatr 2001;68(6):561-2.

[4] Zerin JM, DiPietro MA, Grignon A, et al. Testicular infarction in the

newborn: ultrasound findings. Pediatr Radiol 1990;20(5):329 -30.

[5] Burge DM. Neonatal testicular torsion and infarction: aetiology and

management. Br J Urol 1987;59(1):70-3.